A problem with polyps

05 May 2015

Mr S was a 35-year-old taxi driver who was visiting his extended family abroad. While he was there he decided to have a routine health check in a private clinic. He told the doctor in the health clinic that he had noticed some rectal bleeding over the previous four months. The doctor did a digital rectal examination and proctoscopy and saw two rectal polyps. He gave Mr S a letter to take to his GP at home, explaining the findings and recommending a colonoscopy to further investigate his bowel. Mr S returned from overseas a week later and made an appointment with his GP, Dr A.

He gave Dr A the letter from the overseas health clinic and explained that he had noticed occasional rectal bleeding. Dr A noted that he had seen one of his colleagues a month before who had seen external haemorrhoids that were bleeding slightly. Dr A advised Mr S to avoid constipation to help with his haemorrhoids. He filed the letter from the health clinic but did not act on it.

The following year Mr S was still bleeding occasionally. He remembered the concerns of the overseas doctor and rang his GP surgery. He was given an appointment with Dr B. He explained that he had seen maroon blood on the toilet paper and in his stool for months and was concerned about the cause. Dr B examined him externally and noticed some simple haemorrhoids. He noted that Mr S was not keen on medication so advised him to drink more fluids and increase his fibre intake.

Mr S tried following this advice for six months, but the bleeding persisted so he visited Dr B again. Dr B did a purely external examination again and documented “simple external piles”. He prescribed anusol suppositories.

Over the next three months Mr S began to lose weight and feel very tired. His wife was concerned that he looked pale. He still had the bleeding and was having episodes of diarrhoea and constipation. He made an appointment with Dr C, another GP from his practice, who arranged for some blood tests, which showed significant iron deficiency anaemia. She referred Mr S to the colorectal team, who diagnosed rectal carcinoma.

He had a panproctocolectomy and the histological diagnosis was of two synchronous rectal carcinomas, Dukes stage C1. Multiple adenomas were found, some with high grade dysplasia, and it was considered that Mr S had Attenuated Polyposis Syndrome.

Mr S and his family were devastated. He struggled through chemotherapy and radiotherapy. He was told that it was not possible to reverse his iliostomy and that his five-year survival rate was 45-55%. He was very angry and made a claim against Dr A for not referring him earlier or taking notice of the overseas health clinic’s recommendations.

Expert opinion

MPS sought the advice of an expert GP. He was critical of Dr A for failing to perform any examination of his own, relying instead on a prior examination by one of his colleagues. He felt that Dr A should have taken a fuller history including possible alteration in bowel habit, weight loss and abdominal pain. He felt that choosing to ignore the recommendations of the overseas clinic without making any attempt to reach his own diagnosis to explain the rectal bleeding failed to provide a reasonable standard of care.

He commented that haemorrhoids are a common cause of rectal bleeding in a 35-year-old but the decision to dismiss the clinic’s advice without adequately assessing the patient could not be defended.

The expert GP was also critical of Dr B. The notes from his two consultations gave no indication that any further history was taken. He felt that he should have conducted a digital rectal examination rather than just an external inspection and that this represented an unreasonable standard of care. He felt that a digital rectal examination would have revealed the polyps and thus a more timely referral.

The opinion of a professor in colorectal surgery was sought. He considered that if Dr A had performed a digital rectal examination at Mr S’s first presentation he would have been able to palpate the polypoid lesion in the lower rectum. This should have raised suspicions such that he would have made the referral for colonoscopy. He felt that Mr S would not have avoided a panproctocolectomy because he had multiple other polyps in his colon and was thought to have Attenuated Polyposis Syndrome.

He did state that if the resection had been done closer to presentation, the tumour would have been more likely to be a Dukes A or B and he would have had a five-year survival rate of 70-95%.

The case went to court and was settled for a high amount.

Learning points

Common, normally benign symptoms can on occasion be more serious.

Be prepared to reassess patients if their symptoms are not resolving by taking a detailed history and conducting a thorough examination.

A diagnosis may need to be revisited on subsequent consultations rather than relying solely on former colleagues’ decisions.

Regardless of the fact someone has a consultation overseas out of context, it is never safe to ignore the findings of those consultations and investigations without properly ruling them out first.

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